Prescribing painkillers such as tramadol should be overhauled in Northern Ireland’s prisons, a medical expert has said.
It comes after a review of the death of a prisoner who had taken significant quantities of prescription drugs during lunchtime lock-up at Maghaberry.
He died from a heart attack and tramadol toxicity.
In some prisons tramadol is not prescribed and a leading doctor in the region has previously said it should be upgraded to a Class A drug.
Pathologist Jack Crane has also expressed concerns.
Dr Rob Hall, who reviewed the case for Prisoner Ombudsman Tom McGonigle, noted there were some prisons were tramadol and pregabalin are not prescribed.
The ombudsman's report said: "In relation to prescribing of tramadol, pregabalin and mirtazapine - all of which are known to be abused in prisons - Dr Hall said this review should be the trigger to overhaul prescribing in Northern Ireland prisons.
"He acknowledged that it will not be easy but advised there is sufficient evidence that alternatives to pregabalin, tramadol and mirtazapine can be safely used."
The retired GP from Suffolk said the prisoner’s non-attendance at a neurologist following an earlier collapse was not followed up and there were missed opportunities to be seen by a doctor after he complained of chest pains.
The inmate, referred to as Mr I, collapsed in his prison cell and was taken to hospital but never regained consciousness. His life support was turned off two days later.
The Ombudsman said the inmate had a longstanding history of abusing prescribed medication and illicit drugs.
Professor McGonigle said his eligibility to hold his own medication was not reviewed when it should have been, which led to him being allowed to retain his medicines for four weeks before his death.
However, Dr Hall said that aspects of Mr I’s care were better in prison than they would have been in the community, in that he was seen regularly by a psychiatrist and his mental healthcare was regularly reviewed.
While in the Care & Supervision Unit (CSU), he had daily access to a nurse, was seen frequently by a GP and nursing records were detailed and of high quality.
The ombudsman said: "Dr Hall's fundamental conclusion was that Mr I's death was not foreseeable. However, it may have been preventable had the causes of his chest pains and collapses been diagnosed."
He also said some aspects of the resuscitation attempt were well-managed.
Others could be improved, in particular the maintenance of emergency equipment, although this would not have affected the outcome for Mr I.
The report made 11 recommendations for improvement, all of which have been accepted.